Nursing Diagnosis

Cues breast feeding Diagnosis Scientific comment Objectives/ visualize of C ar nursing Interventions principle valuation S> Hindi pa masyado magaling ang sugat ko as explicit by the patientO> S/P Appendectomy>with running(a) incision at overcompensately lower ab ara>with dry total training on the running(a) lay Impaired Skin Integrity link up to to pelt/tissue trauma Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower group AB tissuesvDisruption of scrape surface and destruction of skin layersvImpaired skin/tissue lawfulness deep down 8 hours of nursing intervention the pt will be able to bare the followinga. ) integral suturesb. ) dry and intact spite fertilizationc. ) participation in passive ROM exercises >Assess mechanic web web site for redness, swelling, loose sutures, or soaked dressing>Monitor Vital Signs> look in passive movements(while 8hrs. lat on have it away) much(prenominal) as bash turning and passive ROM exercise and active exercise thenceforth movements much(prenominal) as bed position, seated, standing, walking> Support incision as in splinting when coughing and during movement>Encourage pt to expressed his for some(prenominal) untoward feelings especially anguish, discomfort as well as changes note on in operation(predicate) site>Encourage pt to submit beforehand(predicate) ambulation and have SOs assist him in much(prenominal) activities> memorise pt and SOs to immediately report when dressing are soaked> instruct pt and SOs to give over from poignant/scratching artist site>Provide uniform dressing financial aid>Administer Chlorampenicol Sodium(antibiotic) as tenacious >to check skin unity, monitor put across of healing and identify need for gain ground> Serve as service line data>to arouse circulation to the surgical site for whilely healing>to lessen pressure on the good site>to allow continuous monitor and dis cernment of pt. ondition>to produce circulation to the surgical site for clockly healing>to promote circulation to the surgical site for timely healing>for immediate replacement to frustrate skin partitioning and contamination of operative site>to avoid appeal of moisture at the operative sitewhich may lead to skin dislocation>to retard bacteria harbor in operative site indoors 8 hours of nursing intervention the pt be able ostensible the followinga. ) intact suturesb. ) dry and intact combat injury dressingc. ) participation in passive ROM exercises> paygrade was not carried out delinquent to time constraints. Pt was endorsed to succeeding members of the wellness team for save circumspection and military rating Cues get by for Diagnosis Scientific translation Objectives/ excogitation of Care nurse Interventions principle Evaluation S>Hindi namn ako nilalagnat carryd by the patientO> v/s taken as followBP110/80 mmHgRR22 cpmPR68 bpmT 37. C> S/P App endectomy>with dry intact dressing on the surgical site Risk for transmittal associate to tissue trauma Inflammation of the appendixvAcute AppendicitisvAppendectomyvTissue trauma on RLQ abdomenMay provide penetration of entry for pathogens through>unnecessary exposure of surgical site> misfortunate aseptic techniques especially in wound dressing>contract with pts, SOs and visitors hands or other partsvMay result to contagion Within 8 hours of nursing intervention the pt will be able state ways in preventing transmittal/contamination specifically proper hand washing, and proper wound electric charge as evidence by>maintain stable v/s>good skin integrity>absence of swelling redness and vexation on operative site >Monitor v/s and record>assess operative site for signs of transmission system>change linens as necessary>Provide unconstipated dressing forethought>Instruct pt and SOs to intermit from base/scratching operative site>Encourage pt to sp eak both changes far-famed on operative site such as redness, swelling and unusual/odorous drainage >Encourage pt to enlist advance(prenominal) ambulation and have SOs assist him in such activities>Administer Penicillin G Sodium(antibiotic) as tell >Elevation in order may signal infection>to provide baseline data for equation and identify need for further wariness>to prevent growth of microorganisms on linens and beds> to prevent unnecessary exposure and contamination of operative sitewhich may clog wound healing>for immediate replacement to prevent skin equipment failure and contamination of operative site>to allow continuous supervise and judgement of pt. condition>to promote circulation to the surgical site for timely healing> coif as prophylactic treatment and prevent bacteria to harbor on operative siteWithin 8 hours of nursing intervention the pt will be able verbalize ways in reventing infection/contamination specifically proper hand washing, a nd proper wound care as certify by>maintain stable v/s>good skin integrity>absence of swelling redness and smart on operative site>Evaluation was not carried out cod to time constraints. Pt was endorsed to succeeding members of the wellness team for further counseling and valuation Kenneth Antonio B. Bacani, SN Group 1 Nursing Care Plan Callang General Hospital, Santiago City Cues Nursing Diagnosis Scientific Explanation Objectives/Plan of Care Nursing Interventions Rationale Evaluation S> Masakit reiterate mark sa baba, while pointing at RLQ of abdomen. >rated twinge as 5 on a scale of 10, where 1 as the lowest and 10 as the highest>characterized disturb as pricking>reported that disorder occurs everytime when pt moves or movedO> v/s taken as followsT 37. CRR 21 cpmPR 64 bpmBP 120/70 mmHg> S/PAppendectomy>with dry intact dressing on the surgical site>with guarding behavior over the site>facial grimacing Acute ache relate to tissue damage 2nd to post appendectomy Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvActivation of nociceptors in dermis and tissuesvReceptors send impulses to CNS for interpretationvPain PerceptionvAcute Pain Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with in solely relieved fuss as evidenced bya. ) verbalization of decrease disturb form 5/10 to 2/10b. engagement in diversional activities such as socialization, honoring TV, and listening mellow music >Monitor V/S and record>Assess pang characteristics including location, meretriciousness, and frequency>Assess surgical site for swelling, redness or loose sutures>Promote adequate relief periods by temporarily limiting activity>Encourage pt to verbalize hassle perception>Provide pt with diversional activities such as socialization, observation TV, and listening mellow music& gtEncourage SOs to report provision of diversional activities and a quiet environment >Administer Toradol (analgesic)as ordered >Elevation in range suggest increased annoyance lastingness and frequency>Elevation in intensity and frequency may delegate worsening condition>Swelling, redness , and loose sutures may contribute to the pain felt by pt. nd are indicative of further prudence>to lessen pain felt aggravated by movements>to allow further assessment of pain characteristics and evaluation of treatment / intervention>to help pt divert his attention to other matters than pain felt>to allow pt cut across divert his attention>to relieved or lessen pain by inhibiting prostaglandin synthesis Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with in alone relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 0/10b. ) engagement in diversional activities such as socialization, ceremonial occasion TV, and listening mellow music>verbal report that pain is completely releived>absence of facial grimacing upon performance of activities such as changing position, seance ,standing and walking> absence of guarding behavior over surgical site>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluationNursing DiagnosisCues Nursing Diagnosis Scientific Explanation Objectives/Plan of Care Nursing Interventions Rationale Evaluation S> Hindi pa masyado magaling ang sugat ko as verbalized by the patientO> S/P Appendectomy>with surgical incision at right lower abdominal area>with dry intact dressing on the surgical site Impaired Skin Integrity link to skin/tissue trauma Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvImpaired skin/tissue integrityWithin 8 hours of nursi ng intervention the pt will be able to manifest the followinga. ) intact suturesb. ) dry and intact wound dressingc. ) participation in passive ROM exercises >Assess operative site for redness, swelling, loose sutures, or soaked dressing>Monitor Vital Signs> facilitate in passive movements(while 8hrs. lat on bed) such as bed turning and passive ROM exercise and active exercise thenceforth movements such as bed position, sitting, standing, walking> Support incision as in splinting when coughing and during movement>Encourage pt to verbalized his for any untoward feelings especially pain, discomfort as well as changes noted on operative site>Encourage pt to engage early ambulation and have SOs assist him in such activities>Instruct pt and SOs to immediately report when dressing are soaked>Instruct pt and SOs to refrain from touching/scratching operative site>Provide regular dressing care>Administer Chlorampenicol Sodium(antibiotic) as ordered >to check skin integ rity, monitor relegate of healing and identify need for further> Serve as baseline data>to promote circulation to the surgical site for timely healing>to squinch pressure on the operative site>to allow continuous monitoring and assessment of pt. ondition>to promote circulation to the surgical site for timely healing>to promote circulation to the surgical site for timely healing>for immediate replacement to prevent skin crack-up and contamination of operative site>to avoid collection of moisture at the operative sitewhich may lead to skin breakdown>to prevent bacteria harbor in operative siteWithin 8 hours of nursing intervention the pt be able manifest the followinga. ) intact suturesb. ) dry and intact wound dressingc. ) participation in passive ROM exercises>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation Cues Nursing Diagnosis Scientific Explanation Object ives/Plan of Care Nursing Interventions Rationale Evaluation S>Hindi namn ako nilalagnat verbalized by the patientO> v/s taken as followBP110/80 mmHgRR22 cpmPR68 bpmT 37. C> S/P Appendectomy>with dry intact dressing on the surgical site Risk for infection link up to tissue trauma Inflammation of the appendixvAcute AppendicitisvAppendectomyvTissue trauma on RLQ abdomenMay provide portal vein of entry for pathogens through>unnecessary exposure of surgical site> pitiable aseptic techniques especially in wound dressing>contract with pts, SOs and visitors hands or other partsvMay result to infection Within 8 hours of nursing intervention the pt will be able verbalize ways in preventing infection/contamination specifically proper hand washing, and proper wound care as evidenced by>maintain stable v/s>good skin integrity>absence of swelling redness and pain on operative site >Monitor v/s and record>assess operative site for signs of infection>change linens as n ecessary>Provide regular dressing care>Instruct pt and SOs to refrain from touching/scratching operative site>Encourage pt to verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage >Encourage pt to engage early ambulation and have SOs assist him in such activities>Administer Penicillin G Sodium(antibiotic) as ordered >Elevation in rates may signal infection>to provide baseline data for equivalence and identify need for further management>to prevent growth of microorganisms on linens and beds> to prevent unnecessary exposure and contamination of operative sitewhich may armed robbery wound healing>for immediate replacement to prevent skin breakdown and contamination of operative site>to allow continuous monitoring and assessment of pt. condition>to promote circulation to the surgical site for timely healing> treat as prophylactic treatment and prevent bacteria to harbor on operative siteWithin 8 hours of nursin g intervention the pt will be able verbalize ways in reventing infection/contamination specifically proper hand washing, and proper wound care as evidenced by>maintain stable v/s>good skin integrity>absence of swelling redness and pain on operative site>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation Kenneth Antonio B. Bacani, SN Group 1 Nursing Care Plan Callang General Hospital, Santiago City Cues Nursing Diagnosis Scientific Explanation Objectives/Plan of Care Nursing Interventions Rationale Evaluation S> Masakit ditto sa baba, while pointing at RLQ of abdomen. >rated pain as 5 on a scale of 10, where 1 as the lowest and 10 as the highest>characterized pain as pricking>reported that pain occurs everytime when pt moves or movedO> v/s taken as followsT 37. CRR 21 cpmPR 64 bpmBP 120/70 mmHg> S/PAppendectomy>with dry intact dressing on the surgical site>with guarding behavior over the site>facial grimacing Acute pain related to tissue damage 2nd to post appendectomy Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvActivation of nociceptors in dermis and tissuesvReceptors send impulses to CNS for interpretationvPain PerceptionvAcute Pain Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 2/10b. engagement in diversional activities such as socialization, observance TV, and listening mellow music >Monitor V/S and record>Assess pain characteristics including location, intensity, and frequency>Assess surgical site for swelling, redness or loose sutures>Promote adequate take a breath periods by temporarily limiting activity>Encourage pt to verbalize pain perception>Provide pt with d iversional activities such as socialization, watching TV, and listening mellow music>Encourage SOs to continue provision of diversional activities and a quiet environment >Administer Toradol (analgesic)as ordered >Elevation in rates suggest increased pain intensity and frequency>Elevation in intensity and frequency may exhibit worsening condition>Swelling, redness , and loose sutures may contribute to the pain felt by pt. nd are indicative of further management>to lessen pain felt aggravated by movements>to allow further assessment of pain characteristics and evaluation of treatment / intervention>to help pt divert his attention to other matters than pain felt>to allow pt continue divert his attention>to relieved or lessen pain by inhibiting prostaglandin synthesis Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 0/10b. ) enga gement in diversional activities such as socialization, watching TV, and listening mellow music>verbal report that pain is completely releived>absence of facial grimacing upon performance of activities such as changing position, sitting ,standing and walking> absence of guarding behavior over surgical site>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation